Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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3. CLOSING

The closed-suction drain is brought out through the anterior abdominal wall on the right side, with care taken to avoid injury to the epigastric vessels.

After irrigation is completed and hemostasis is ensured, fascial closure is performed per surgeon preference. Running or interrupted and permanent or absorbable sutures may be used per surgeon preference.

The skin is closed with a 4-0 Monocryl subcuticular suture or skin staples.

STEP 4: POSTOPERATIVE CARE

Postoperative complications included hematoma, bleeding, or leakage from the duodenotomy.

The output from the operatively placed drain should be monitored. This fluid may be bilious or amylase-rich if a leak is present at the duodenotomy. If unsure, the drained fluid can be sent for amylase and bilirubin levels, which should be less than three times the current serum levels.

Diet can be quickly advanced to normal by 2 to 4 days postoperative.

The drain should not be removed until the patient is tolerating a regular diet. The regular diet stimulates pancreatic secretion, and duodenal leaks may not be evident until the patient is tolerating a regular diet.

STEP 5: PEARLS AND PITFALLS

It is helpful to place a biliary balloon catheter through the CBD and into the duodenum before making your duodenectomy. This is most easily achieved by inserting the catheter through the cystic duct in a patient who has not had a cholecystectomy, as shown previously.

If the patient has already had a cholecystectomy, the catheter can be placed through a small choledochotomy in the CBD.

If gallstones are obstructing the CBD and the catheter cannot be passed, the incision should be made in the second portion of the duodenum. After the ampulla of Vater is identified, the incision can be elongated.

The ampulla of Vater can be cannulated retrogradely after the ampulla of Vater is identified, because it is easier to perform the sphincterotomy over a probe or catheter.

When attempting to cannulate the minor papilla, take great care not to create a hematoma. If a hematoma forms it may be impossible to cannulate the pancreatic duct at the minor papilla.

SELECTED REFERENCES

1. Mulholland MW, Lillemoe KD, Doherty GM, et al (eds): Greenfield’s Surgery: Scientific Principles and Practice, 4th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.

2. Zuidema GD, Yeo CJ, Turcotte J (eds): Shackelford’s Surgery of the Alimentary Tract, 5th ed. Philadelphia, Saunders, 2002.

3. Cameron JL (ed): Atlas of Surgery: Gallbladder and Biliary Tract, the Liver, Portasystemic Shunts, the Pancreas, vol 1. Philadelphia, BC Decker, 1990.

4. Cameron JL (ed): Current Surgical Therapy, 8th ed. Philadelphia, Mosby, 2002.

STEP 2: PREOPERATIVE CONSIDERATIONS

Due to the magnitude of hepatic surgery, one first consideration is the medical status of the patient and likely risk of surgery. Thus one must exclude significant coronary, pulmonary, or renal disease or age and frailty. Of particular concern in relation to hepatic surgery is the underlying hepatic function. Because hepatocellular carcinoma is associated with prior hepatitis and cirrhosis, one must determine first whether cirrhosis exists and second what level of function is apparent. Historically, this was measured by examining synthetic and excretory functions and measures of portal hypertension (serum albumin level, coagulation profile, serum bilirubin level, ascites, and mental status/serum ammonia). More recently, the Model for End-Stage Liver Disease (MELD) score was developed as a means of segregating candidates for liver transplant. This system incorporates prior variables, but has added and places considerable significance to renal function. Particularly when one anticipates a major resection, one must establish that sufficient liver will remain to support life. Unfortunately, this estimate of “hepatic reserve” is even today an inexact science.

Nutritional status, renal function, degree of ascites, and coagulation abnormalities are all factors that may be improved by medical management before surgery. Unfortunately, we have personal experience that such patients may thereby achieve an improved functional grade but appear to carry a risk that exceeds the risk in patients who have had this improved functional status without a need for medical manipulation to achieve it.

In the case of malignancy, one must establish that curative resection is clinically achievable.

STEP 3: OPERATIVE STEPS

1.INCISION

We prefer the inverted L incision.This incision offers the option of extending the horizontal component of the incision either laterally into the right flank or medially across the midline. The vertical component of the incision can be extended toward the xiphoid process. By then placing self-retaining retractors, the exposure of the right upper abdomen is maximized. The incision can be extended if the operative view is inadequate.

2.DISSECTION

First, the concept of nonanatomic resections encompasses wedge resections, which do not require individual segmental dissection. The term also encompasses the many variations on segmental or multisegmental resections.

For wedge resection, most surgeons will use a combination of total inflow occlusion with compression of the hepatoduodenal ligament combined with local compression at the site of resection.

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For segmental resection, although a vast variety of procedures are included in this category, the concept is the same. Vascular control is obtained by dissecting along the hepatoduodenal ligament and accessing and temporarily or permanently occluding the vessels corresponding to that segment or the primary feeding vessel to that segment. To illustrate, we will describe the steps involved in resection of segment VIII (Figure 44-7).

Inferior to the liver edge, divide the falciform ligament between clamps and tie with heavy silk suture. Cut the sutures at the caudal divided ligament. Place a hemostat on the uncut cephalad end of suture on the divided ligament for use in manipulating the liver during dissection. You will discover the need for a constant balance between retracting the liver cephalad and retracting caudad. Using this tether, you may restore some caudal exposure while the self-retaining retractor suspends the liver toward the diaphragm (Figure 44-8).

Using electrocautery, the filmy, avascular falciform ligament is incised beginning at its attachment to the anterior abdominal wall and continuing in a cephalad and dorsal direction up to the point of convergence of this ligament with the left and right triangular ligaments. The hepatic veins are visualized at the superior extent of this dissection. Carefully incise the peritoneal surface to clearly define the right and middle hepatic veins. We favor placing a vessel loop around the right and middle hepatic veins at this juncture.